Is rising maternal mortality just hype? Nope, here’s why.

The high maternal mortality rate in the U.S. has been a matter of great interest and debate, spurring a reflective look into our health care system to determine why our country is on the wrong end of this statistic. The reasons and numbers vary across the country and notably in the state of Maryland, which has had a higher than average maternal mortality rate, the number of maternal deaths continues to increase at a rapid pace.

In a comparison of two study periods (2005–2009) to (2010–2014), while the maternal mortality rate increased by an astounding 32 percent nationwide, it increased by an even more astounding 51 percent in Maryland.

I must admit, as an obstetrician-gynecologist, I was skeptical of the media hype regarding maternal mortality in the U.S. compared to other countries with less advanced technology and more limited access to medications and high-quality medical care.

However, there is no denying the fact that the rate is indeed increasing. As I think about these statistics, it becomes clear to me that there are two major crises in the field of women’s health.

Maternal mortality

The causes vary, but as discovered in the Maryland Maternal Mortality Review Program in 2014, the leading cause of death of pregnant women was substance abuse disorder: unintentional overdose. Meanwhile, the leading cause of death directly associated with pregnancy was hemorrhage.

Death by drugs can be experienced by anyone, but death directly associated with pregnancy can only be experienced by the pregnant. This difference is important.

On news outlets, social media, and magazines you have likely heard stories about the loss of a pregnant mother or postpartum patient under horrible circumstances of medical negligence or some preventable health cause. These stories are heartbreaking and infuriating and should not happen — especially in this country. These types of stories also bring ratings, clicks, followers, etc. and are unfortunately also a contributing cause for the growing distrust of physicians based on a very small minority picture of the problem at hand.

The important piece to consider is that a woman who overdoses while pregnant is also considered in overall pregnancy death statistics. Again, overdose was the number one cause of pregnancy-associated death. The U.S. is facing an opioid epidemic, and pregnant women are not spared from this.

Substance abuse prevention and treatment programs during pregnancy will be paramount in reducing the number of maternal mortalities.

More research is needed to determine the complete impact drug use has on our maternal mortality statistic.

Hemorrhage treatment is also an area where we can improve, and an effort has been made to have massive transfusion protocols and training in hospitals. This is a start.

OB/GYN shortage

Is our country’s shortage of obstetricians linked to our high maternal mortality rate? I don’t think we have the evidence to support this notion. However, we may start to see concerns in the coming years as this shortage becomes more pressing.

In the state of Nevada, there are 11 (out of 17) counties without a single practicing ob-gyn. Nevada’s female population is expected to increase by 64 percent by 2030, while the total U.S. female population is expected to increase by 17 percent.

There are 2.08 OB/GYNs per 10,000 women in this state.

By the year 2030, the U.S. is expected to have an 18 percent (9000) shortage of OB/GYNs.

These numbers are outrageous. And it is obviously not limited to the state of Nevada but a nationwide concern. What is causing this OB/GYN shortage not only in Nevada but across the country? Well, the task force also noted an increase in the population of women in the U.S. of 26 percent since 1980, but the number of OB/GYNs trained has remained stagnant due to limited residency training spots that are still filling each match day. Medical students still remain eager to enter the field of OB/GYN, although with some trepidation and concerns regarding lifestyle and malpractice premiums. The problem arises after they finish residency.

We are starting to see an aging OB/GYN workforce. In addition, physicians are working decreased hours and are retiring early from obstetrics. More recently, OB/GYN residents are opting to avoid obstetrics altogether and are choosing to sub-specialize at increasing rates in fields such as minimally invasive gynecologic surgery, urogynecology, and gynecologic oncology. Work-life balance can be better in these fields, and malpractice premiums are also much lower. Maintaining our current OB/GYN workforce should be a top priority. This starts with supporting them by finally obtaining meaningful liability reform, sustainable working conditions, a positive PR campaign and increasing the number of residency spots (especially in states such as Nevada with urgent needs).

If we don’t address the obstetrician shortage, we will burn out the ones still in the field. It is not good for our physicians and, more importantly, our patients to have a limited supply of medical knowledge and expertise. In our efforts to decrease the maternal mortality rate in the U.S., the OB/GYN shortage must also be addressed.

Valerie A. Jones is a obstetrician-gynecologist who blogs at OB Doctor Mom.

Is rising maternal mortality just hype? Nope, here’s why. 7 comments

I think I would settle for transparency in maternal mortality statistics and malpractice reform!

InklingBooks

Thanks for a great article, particularly the closing remark about a catch-22. Fewer obstetricians means more work falling on those remaining, which then means more burnout and few obstetricians to bear the load.

But unfortunately you did not deal with what may be a major factor, and one that’s apparently true in your own life. OB/GYN is becoming a mostly female speciality. In one sense, that’s good. It makes sense for female problems to be treated by women. But that has a downside. Women in medicine tend not to work insanely long hours and often drop out or scale back to be mothers. Again, that’s good for their kids, but who is left to care for the other mothers?

There’s also a factor that been slowly increasing since so much fell apart in the 1960s. It’s illustrated by some statistics I recall that found that married women with only a high school education had better pregnancy outcomes than single women with college degrees. The factor, I suspect, is the presence of a husband who’s making sure nothing goes wrong. To what extent are these dreadful statistics linked not just to drugs but to single parenthood?

The hatred that greeted Charles Murray’s Coming Apart illustrates what happens when someone brings up that topic, even in a white-only context. Which is, of course, utterly insane. The reason it takes two to make a baby is similar to why commercial jets have two pilots. In a pinch, there’s more to be done than one person can handle, whether it’s a pregnancy, a child, or a plane filled with passengers.

And I’d love for someone to explain to me why there is a shortage of residency slots. Given the cheap labor and long hours they provide, does it really cost more to supervise them than their labor is worth? If not, why not expand the hospital offering residencies? It’d take some of the load off established physicians, including those in OB/GYN.

And for those who’d like to see how women medical students view residency, here’s a delightful video. Alas, there is no mention of an OB/GYN residency.

Thank you for contributing to the discussion of these important issues. However, I do think it is unfair to lump all female physicians into stereotypical paths in regards to their families or their careers. I see physcians of both genders dropping the obstetrics part of ob/gyn when they are able to, and both genders deciding to subspecialize as oppose to entering obstetrics. I do agree with your comment that the labor of ob/gyn resident physicians is worth far more than what they are paid and it most certainly would make sense to increase the number of residency spots. The salary of residents are paid for by the government, and ACOG (as well as other ob/gyn advocacy groups) are indeed calling for an increase in residency positions, especially in areas of the country with extreme ob/gyn shortages at present.

AltarofEeyore

I see no mention of suicide in these statistics, either.

Well, I guess it’s not really an issue with which legislators feel the need to concern themselves.

Louise

Texas has the highest maternal mortality rate in country. In 2010 GOP-controlled Legislature passed new laws affecting Planned Parenthood Clinics which forced the closure of many of them across this large state – especially in rural areas. The state did NOT replace facilities or funding! for women who used these PP clinics for their reproductive health care to have access to other medical facilities. Beginning in 2012 it was obvious rate of maternal mortalities (along with 27% jump in unplanned pregnancies and much higher premature birth rates!) was skyrocketing! In their Spring article, “Journal of Obstetrics & Gynecology” called the Texas maternal mortality rate “the highest in the developed world . . . ” Death rates related to pregnancy/birth complications in Texas are now 38/100,000 women. Compared to maternal mortality rates across Europe, with its various systems of universal medical care access, of 4 – 6 / 100,000!!

Yes, thank you for commenting about the very real problem occurring specifically in Texas. We can and should do better in this country. The reasons behind the increasing mortality rates differ even state by state and need to be further studied. Unfortunately, the media has propelled the idea that physicians/hospital birth in this country are to blame (by jumping to unsubstantiated conclusions) but that is doing a disservice to our patients by not giving them the facts behind the numbers.